Mystery Illness Seen in Washington State – AFM (Acute Flaccid Myelitis)

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Very recently, a handful of patients (8 children) in Washington State have recently been diagnosed with AFM (Acute Flaccid Myelitis) which is a rare condition that affects the central nervous system (spinal cord) and cause weakness in arms/legs, and possibly facial droop/weakness, difficulty with moving they eyes, drooping eyelids and/or difficulty with speech or swallowing. As of September, 2016 – 89 people in 33 states were confirmed to have the rare illness according to the CDC website.

Diagnosis:  If you think you or a family member has this condition, you should seek consultation with a medical provider.  But how do you know if it’s AFM that is causing the symptoms?  A doctor may be able to diagnose AFM by doing a careful examination and sometimes an MRI may also be helpful in assisting in the diagnosis.  An examination of the spinal fluid (which surrounds the brain) may be collected by a spinal tap (lumbar puncture) procedure and may aid in the diagnosis.

There are also nerve tests that can be done which may also aid in the diagnosis however they have to be done at 7-10 days after the onset of the illness.

Causes:  There are a number of viruses which have been though to possibly be the causal agents in the disease including enteroviruses (including polio), West Nile Virus, Japanese Encephalitis, Saint Luis Encephalitis, and various adenoviruses.

AFM is not the only cause of weakness in arms or legs:  Other causes can include viral infections, environmental toxins, genetic disorders, or GBS (Guillain-Barre syndrome).  There are neurological disorders such as stroke (cerebral vascular accident) that can also cause weakness in an arm or leg or facial drooping so it’s important to seem medical attention immediately (call 911) if you or someone you know has these symptoms.

Treatment:  No specific treatment exists for AFM, however a neurologist (nerve specialist) may be consulted to help make recommendations and help with the diagnosis.

If you or your child is having problems walking or standing, or develop sudden weakness in an arm or leg, you should contact a medical provider right away.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

*This information comes from the CDC website About Acute Flaccid Myelitis

Epidermal Inclusion Cysts

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Photo credit: http://en.wikipedia.org/wiki/Sebaceous_cyst

Patients will often come into the urgent care with a small skin lump that has become red and/or painful.  Often if they think back, they might recall feeling a small nodule under the skin in that same area perhaps months or years before it became swollen and red.  The epidermal inclusion cyst is one of the most common skin cysts and can occur anywhere on the body but they are more common on the face or upper body. Most of the time, these cysts do not cause any problems, but can sometimes be cosmetically unpleasing.

Other names for epidermal cysts:

1)   Epidermoid cyst

2)   Sebaceous cyst

3)   Keratin cyst

4)   Epidermal inclusion cyst

5)   Infundibular cyst

Appearance:  Epidermal cysts have a cyst wall that is make of skin cells of the outside layer of the skin called the epidermis.  The cyst wall is like a balloon that goes down into the second layer of skin called the dermis.  The cyst wall/balloon makes a protein found in the skin/nails called keratin that is usually white, cheesy or firm in consistency.   It is often foul smelling as well.

Cyst Rupture:  If the cyst wall ruptures underneath the skin (usually due to trauma or bumping the area unintentionally), the keratin (cheesy white material) comes out and is exposed to the surrounding tissues and is very irritating.  It can make the skin become red, swollen and painful.  It’s best to see your doctor instead of trying to “pop” or drain the cyst yourself.  Sometimes your doctor may recommend treating you with an oral antibiotic before opening the cyst if he/she thinks that the cyst has become infected.

How epidermal cysts are removed:  If the cyst needs to be removed, your doctor will try to remove the entire cyst including the cyst wall.  Remember, the cyst wall is what makes the keratin (that cheesy white material inside the cyst).   If the cyst wall is allowed to remain underneath the surface of your skin, it may start making more keratin which can cause the cyst to come back.

Usually we make an incision over the cyst and separate the underlying skin from the cyst wall and try to remove it in one piece.  If the cyst has ruptured (which is most likely brought the patient in), the cyst is removed in a piecemeal fashion with an attempt to get all of the keratin, and cyst wall out.  The doctor may irrigate the  wound with sterile solution after the procedure.  The skin is usually left open and not stitched.  The doctor may place a small piece of packing gauze under the skin where the cyst was and then put a bandage over it.  This will allow the wound to drain while it’s healing.  The wound is usually examined by a medical provider every 2-3 days to check on the healing process and part or all of the packing gauze will usually be removed.

The reason that your medical provider may put some sterile gauze inside the wound and ask you to come back to be reexamined instead of just putting some stitches over the wound is because sometimes these areas can be infected with bacteria and if the skin is closed right away with sutures, the bacteria will have a small pocket under the skin to grow and form an abscess.  If the wound is allowed to heal from the inside out, there is less chance of an abscess forming and wound healing can happen more quickly.

When to have a cyst removed:  If it’s small and doesn’t hurt and isn’t painful/red/swollen, it probably doesn’t need to be removed.  I might recommend removing a cyst if:

1)   It keeps getting red and irritated or infected

2)   It’s getting larger quickly

3)   It’s in a place that rubs against your clothes or jewelry and gets irritated

4)   If it becomes red, inflamed or painful

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

What is a Pressure Ulcer (AKA Pressure sore)?

shutterstock_89421025bed-soresPhoto credit:  http://diseasespictures.com/bedsores/

A patient came in to see me today with a sore on his heel that’s been bothering him for the past few months.  He’s diabetic and has lost feeling in the bottom of his feet.  He’s had these pressure sores in the past but has trouble getting them to heal up.

Pressure sore:  Areas of skin that have been damaged by pressure such as sitting or lying in one position for a very long period of time.  They can also be called “bedsores.”  The are more commonly found in areas of the body where the bone is near the surface of the skin such as on the hips, elbows, ankles and back/buttocks. The skin and soft tissues become damaged because not enough oxygenated blood can get to the area to promote healing usually due to the compression of the damaged skin and soft against hard bone tissue.

Appearance:  The sores change in the way they look depending on how long they’ve been present and how much damage has been done.  In the beginning, the sore appears as a small red patch of skin, and if not treated, the skin will break down and cause a hole or crater to form (we call this an ulcer).

Stage 1:  The skin is intact without ulcers but when you push on the skin it does not change colors to indicate good blood flow.  Usually, healthy tissue will be pink and when you push on the area with your finger you can notice it will become less pink and in a couple seconds the pinkness will return.  This does not happen in the damaged skin at this stage – it may have a darkly pigmented color.

Stage 2:  There is an open, shallow ulcer with a red-pink color at the base of the wound.  Sometimes there may be blisters present which are either intact or ruptured.

Stage 3:  Structures beneath the skin such as fat may be exposed but at this stage, you should not see bone, tendons or muscle tissue.

Stage 4:  Structures beneath this skin including bone, tendon and muscle may be seen in the bottom part of the ulcer

People at Risk:  Some patients are more at risk than others of getting pressure sores.

1)   Patients who cannot move very well because they have a medical problem.  These people may sit or lay in one position for a long time.  They need help to move to a different position so that the skin doesn’t form sores.

2)   Older people are more prone to pressure sores because they often don’t move around as much and their skin is more fragile and thinner than a younger person.

3)   Patients who have diabetes or nerve problems in their feet may not feel when a small pebble or area gets into their shoe or pressure pushes on the foot causing injury.

4)   Patients in the hospital or nursing home are at especially high risk for many of the factors noted above – increased age, decreased mobility, and other complicated medical problems.

Prevention:  Some things can be done to lower the chances of getting pressure sores

1)   Repositioning the patient’s body every two hours so that they are not lying on one area where the skin is being crushed, pinched or pressure is building

2)   Putting pillows between the ankles and knees to decrease the pressure on the skin over these boney areas

3)   Raising the head of the bed when the patient is lying on their side to decrease the pressure on the hip bone

4)   Getting special foam or soft mattresses that decrease the pressure on the areas of the body that have the most pressure on them

For patients in wheelchairs:

1)   Use a special cushioned seat if possible to prevent pressure on the sacrum

2)   Every hour tilt forward or to the side to release pressure on the seat

3)   If ankles or heels press on the chair, use foam padding to protect against sores

4)   Check skin regularly for signs of pressure or ulcers

Treatment:  Pressure sores are treated differently depending on the stage of ulceration and how severe the damage to the skin is.

1)   If there is mild erythema, the treatment is generally off-loading the area but decreasing the amount of time that this area is compressed by body re-positioning, and/or using pillows to cushion the area.  We also use transparent films over the ulcers to protect the areas.

2)   In patients who have diabetes, adequately managing blood sugars to keep them under good control is very important.  Elevated blood sugars impede wound healing.

3)   If there is dead or dying skin or soft tissues, this often needs to be removed to help prevent infection.

4)   Special bandages may be needed to keep the healing tissue moist but prevent tissue maceration (from being too moist). Sometimes the dressings that we use to treat wounds can be very expensive.

5)   Antibiotics may be prescribed if there is a wound infection

6)   Medication for pain may also be prescribed

There are some tools to score the pressure and grade the healing process.  These are helpful for patients who come back for repeat visits to wound care clinic or their primary care provider and there is a need to grade the healing by giving them a score.  Some clinical features that are examined include:

1)   Amount of Exudate

2)   Skin color surrounding the wound

3)   Peripheral tissue swelling

4)   Peripheral tissue firmness around the wound

5)   Amount of granulation (healing) tissue

6)   How much epithilization is present

It’s important to optimize the nutritional status of patients with wounds.  Particularly for patients who have Stage 3 and 4 ulcers, they need enough protein and calories to help heal these wounds.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

What you need to know about the HPV (Human Papillomavirus Vaccine)

shutterstock_167922080One of the most controversial topics in medicine recently has been the HPV vaccine.  It can save lives by helping prevent cervical cancer but must be given at an early age.

What is HPV?  Genital human papillomavirus (HPV) is the most common sexually transmitted virus in the United States.  More than half of sexually active men and women are infected with HPV at some time sin their lives.

About 20 million American are currently infected, and about 6 million more get infected each year.  HPV is usually spread through sexual contact.

Most HPV infections don’t cause any symptoms, and go away on their own.  HPV can cause cervical cancer in women.  Cervical cancer is the 2nd leading cause of cancer deaths among women around the world.  In the United States, about 12,000 women get cervical cancer every year about 4,000 are expected to die from it.

HPV is also associated with several less common cancers, such as vaginal and vulvar cancers in women, and anal and oropharyngeal (back of the throat, including base of the tongue and tonsils) cancers in both men and women.  HPV can also cause genital warts and warts in the throat.

There is no cure for HPV infection, but some of the problems it causes can be treated.

HPV vaccine: Why get vaccinated?  The HPV vaccine is one of two vaccines that can be given to prevent HPV.  It may be given to both males and females. This vaccine can prevent most cases of cervical cancer in females, if it is given before exposure to the virus.  In addition, it can prevent vaginal and vulvar cancer in females, genital warts and anal cancer in both males and females.  Protection from HPV vaccine is expected to be long-lasting.  Vaccination however is not a substitute for cervical cancer screening.  Women should still get regular Pap tests.

Who should get the HPV vaccine and when?  HPV vaccine is given as a 3-dose series.  The first dose is initially given, with the second dose 1-2 months after the first dose and the final third dose is given 6 months after dose 1. Additional (booster) doses are not recommended.  The HPV vaccine is recommended for girls and boys 11 or 12 years of age.  It may be given starting at age 9.

Why is HPV vaccine recommended at 11 or 12 years of age?  HPV infection is easily acquired, even with only one sex partner.  That is why it is important to get HPV vaccine before any sexual contact takes place.  Also, response to the vaccine is better at this age than at older ages.

Catch-Up Vaccination:  This vaccine is recommended for females ages 13-26 years of age who have not completed the 3-dose series or males 13-21 years old who have not completed the 3-dose series.  This vaccine maybe given to men 22 through 26 years of age who have not completed the 3-dose series. It is recommended for men through age 26 who have sex with men or whose immune system is weakened because of HIV infection, illness or medications.   It may be given at the same time as other vaccines.

Some people should not get HPV vaccine or should wait:  Anyone who has ever had a life-threatening allergic reaction to any component of the HPV vaccine, or to a previous dose of HPV vaccine, should not get the vaccine.  Tell your doctor if the patient has any severe allergies, including an allergy to yeast. HPV vaccine is not recommended for pregnant women, however receiving the vaccine when pregnant is not a reason to consider terminating the pregnancy.  Women who are breast feeding may get the vaccine.  Any woman who learns that she is pregnant when she got the vaccine is encourage to contact the manufacturer’s HPV-in-pregnancy registry at 800-986-8999.  This will help us learn more about how pregnant women respond to the vaccine.

What are the risks from this vaccine?  The HPV vaccine has been used in the U.S. and around the world for about six years and has been very safe.  Any medication however could possibly cause a serious problem or severe allergic reaction.  The risk of vaccines causing serious injury or death however is very small.  Life-threatening allergic reactions from vaccines are very rare.  If they do occur, it would happen within a few minutes to hours after the vaccination.  Several mild to moderate problems are known to occur with this vaccine.  These symptoms do not last long and go away on their own.

1)      Reactions in the arm where the shot was given

2)     Pain around the injection site

3)     Redness or swelling around the injection site

4)     Mild fever up to 100 degrees F

5)     Moderate fever up to 102 degrees F

6)     Headache

7)     Fainting during the procedure – usually caused from being nervous

What if there is a moderate or severe reaction – what should I look for?  Any unusual condition such as high fever or behavior changes of the person who received the vaccination.  Signs of a serious allergic reaction can include difficulty breathing, hoarseness or wheezing, hives, paleness, weakness, fast heart rate or dizziness.  If any of these occur, call a medical provider or 911 immediately.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

This information comes from the U.S. Department of Health and Human Services Centers for Disease Control and Prevention (CDC).

Diabetes Foot Care

shutterstock_110360354Patients who have diabetes need to pay extra attention to their foot care to help prevent infections.  I’ve had numerous patients with diabetes need foot or toe amputations that could have been prevented with excellent foot hygiene.  Small scrapes in the skin or ingrown nails can become extremely bad very quickly with diabetes because patients who have diabetes often don’t have as much sensation (due to damage to the nerve endings and blood vessels in your feet).  This can make it difficult to detect sores and once an infection is present it can be very difficult to treat.  I thought I’d put together some tips to help you keep your feet healthy and decrease the risk for infections.

1)      Stop smoking:  If you smoke, this can decrease the blood flowing to your feet and make foot problems worse.

2)     Inspect your feet everyday:  Look for blisters, cuts, cracks or sores.  If you cannot see your feet well then use a mirror or have a family member help you.

3)     Wash your feet everyday:  Use warm (not hot) water – be sure to check the temperature with your hands rather than your feet.

4)     Dry your feet well:  Pat them dry and do not rub the skin on your feet too hard.  Dry between each toe.  If the skin on your feet stays moist, bacteria or fungus can grow and that might lead to a foot infection.

5)     Keep your feet soft:  Use a skin moisturizer such as Aveeno, Dove or Cetaphil on your feet to keep your skin soft and prevent calluses and cracks.  Don’t put the cream between your toes unless you are treating athlete’s foot with a fungal cream.  Make sure to wear socks or traction on your feet after applying the cream so you don’t slip and fall.

6)     Clean under your toenails carefully:  Don’t use sharp objects under your toenails.  Instead use the blunt end of a nail file or other rounded tool to decrease the chance of piercing the skin.

7)     Trim and file your toenails straight across:  This helps prevent ingrown nails.  Use a nail clipper instead of scissors.  Then use an emery board to smooth the edges.  If you need help trimming your nails, schedule an appointment with your medical provider.

8)     Change your socks everyday:  Socks should have a thick cushion and fit loosely around your feet.  Socks without seams are best because seams often rub the feet.  Do not wear stockings, socks, or garters that come up to the thigh or knees unless your medical provider advises you to do so because they can decrease the blood flow to your feet.

9)     Look inside your shoes before putting them on:  Check them every day for gravel, torn linings, or thorns that can cause blisters or sores.

10)  Do not go barefoot:  Don’t wear sandals or shoes with thin soles because these types of shoes are easy to puncture.  They also do not protect your feet from hot pavement or cold weather.

11)  Have your medical provider check your feet during each visit:  If you notice a problem with your feet, see your medical provider right away rather than trying to treat it with a home remedy.  Some home remedies or treatments that you can buy without a prescription (such as corn removers) can be harmful.

12)  Keep your blood sugar down:  Watch what and how you eat, monitor your blood sugar, take your medications and get regular exercise.

When to seek medical help:

A)      If you cannot do proper foot care

B)     If you have a foot sore or ulcer that is not healing after 3 days (including corns, calluses or ingrown nails)

C)     If you have black and blue areas in your toes or feet

D)    If you have peeling skin or blisters between your toes

E)     If you have a fever for more than 24 hours and a foot sore

F)     If you have new numbness or tingling in your feet that does not go away after you move your feet or change positions

G)    If you have unexplained or unusual swelling of your foot or ankle

H)    Anytime you have questions about your feet or concerns it is best to contact your medical provider

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

What to do about the common skin wart

 

shutterstock_115521190shutterstock_148362410I often have people come into the clinic and ask me to treat warts, mostly on their hands or their feet.  Some people aren’t aware of what these are so I thought a brief discussion might help people identify warts and also mention some common treatments.

Common skin warts are generally non-dangerous raised and round or oval shaped skin growths that often stick up compared to the surrounding skin.  If they’ve been present for months or years, they can sometimes become rather large or form patches that appear like a cauliflower shaped lesion.  Sometimes they are identified by tiny black spots or dots that are small, clotted blood vessels but some people call them “seeds.”

What causes a wart?  Warts are actually the result of a virus (human papillomavirus) and is spread by touching someone else’s skin who has a wart.  They’re also often spread by picking at existing warts and touching other areas on your own body.  The virus lives in skin surrounding the wart and can be spread easily by scratching are removing some of the virus under your finger nails.  Warts can also be spread by coming into contact with skin cells that have fallen off an infected persons foot.  It can actually take up to six months after exposure to the virus for a wart to appear.

What are the most common areas where warts occur on the body?  The most common areas of the body for warts are:

1)     Fingers

2)     Hands

3)     Knees

4)     Elbows

5)     Around the fingernails (periungual warts)

6)     Feet (plantar warts)

7)     Face

8)     Lower legs

How do I know if I have a wart or if the skin lesion is due to something else?  Usually a medical provider can diagnose a wart based on how it looks.  A biopsy is not usually required.

Once I know that I have a wart, how do I get rid of it?  Warts can be very difficult to treat and there are many different options for treating warts.  The treatment of choice often depends on where there wart is located and how sensitive the skin is.  Some possible treatment options are:

1)      Leave it alone – about 67% of all warts will go away within two years even if not treated.  Most people treat then however because they can spread or become larger over time.

2)     Liquid nitrogen:  In the doctor’s office, we usually use this very cold liquid to freeze the skin around the wart.  It can be painful so it can be a difficult treatment for young children to tolerate.  We often need to treat a wart several times using liquid nitrogen and if the wart is large, we may need to trim the top part of the wart off to make the treatment more effective.

3)     Salicylic acid:  Over the counter patches employ this kind of treatment.  Usually a liquid or patch is applied to wart and left in place for several days.  It is often helpful to soak the skin in warm water for 10-20 minutes before applying the acid to soften the skin.  Treatment with salicylic acid can be painful and cause redness to the skin and even bleeding.  Many people find that using a nail file or pumice stone is helpful to gently remove the dead skin from the surface of the wart every few days during the treatment.  You should be cautious when doing this however because there is a high risk of spreading the virus/warts to other areas on the body when using a file or stone.  I usually recommend using a new file or stone each time to help prevent spreading the wart virus.  Most people don’t realize that you need to keep applying the acid each day for 1-2 weeks even after the wart is gone because the virus can be present on the skin even if no wart is visible.  This helps ensure that the wart does not return weeks or months later.

4)     Duct tape:  The sticky tape easily found in most home improvement stores has been helpful to some people with warts.  They apply it directly to the skin over the wart and leave it in place for about a week.  It’s not entirely clear how the treatment works, but my thought is that the tap sticks to the surface of the skin where the wart is present and the tape on the skin causes moisture to build up and this makes it easier to remove the dead skin cells (containing the wart virus) when the tape is removed.  Many people use an emery board or pumice stone to remove the excess skin after removing the tape and then reapply the tape for another week.  It may take up to 4 weeks for the wart to go away using this treatment.  We usually don’t recommend using duct tape if you have diabetes because if you cover your skin and a bacterial infection begins, you might not be able to see it starting and an infection may get very large before it is noticed.

5)     Cantharidin:  This is a liquid that is prescribed by healthcare providers such as a dermatologist and applied directly to the wart on the skin.  It may cause a blister to appear over the wart after 2-24 hours of treatment.  It is usually just placed on the skin once and often dermatologists will recommend using salicylic acid for a week after the skin heals to decrease the chances of the wart coming back.

6)     Imiquimod:  Aldera is the other name for this prescription cream that is applied at bed time several times per week.  It works by stimulating the immune system to fight off the wart virus.  It is rather expensive and is usually prescribed for genital warts or another type of virus called condyloma acuminate.  It can also be used to treat small skin basal cell skin cancers or pre-cancers.

7)     5-Fluorouracil:  This cream which also goes by the name Carac, Efudex or Fluroplex is applied to flat warts twice a day for 3-5 weeks.  We also use this cream to treat small skin pre-cancers and superficial basal cell cancers.  It can cause skin irritation especially for those people who get lots of sun exposure.

8)     Shave excision:  This is a procedure where the skin is cut away or removed where the wart is present on the body.  This procedure is not very common for treating warts because it can cause permanent skin scarring or keloid formation and may also require stiches after the procedure.

9)     Immunotherapy:  A dermatologist (skin doctor) may inject a medication directly into the wart that triggers the body’s natural immune system to attack the virus.  These medications called contact sensitizers are not widely used because they are highly potent, expensive and require careful handling to avoid causing unintentional allergic reactions.

Should I see a doctor to treat my wart?  I’d recommend seeking the help of a medical provider if you are not sure that the skin growth is a wart, if it’s not improving with home treatment, if you have questions about what treatment is best for you or if you have been treated for warts before and have developed a complication such as a skin infection or scar.

Where can I get more information?  The following sources may be helpful:

1)      American Academy of Dermatology:  www.aad.org/skin-conditions/dermatology-a-to-z/warts

2)     Medline Plus:  www.nlm.nih.gov/medlineplus/ency/article/000885.htm

References:

1)     Gibbs S, Harvey I. Topical treatments for cutaneous warts.  Cochrane Database Syst Rev 2006

2)     Moed L, Shwayder TA, Chang MW. Cantharidin revisted: a blistering defense of an ancient medicine. Arch Dermatol 2001; 137:1357

3)     Muzio G, Massone C, Rebora A. Treatment of non-genital warts with topical imiquimod 5% cream. Eur J Dermatol 2002; 12:347

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

Sexually Transmitted Infections – “So you want to be tested for everything…”

shutterstock_36483805I frequently have patients come into the office and ask for STI (sexually transmitted infections) screening.  This is often done when they start a new relationship, when they find out that a partner has been unfaithful or if they have unprotected sex with someone that they don’t know well.  Patients often have no understanding of which sexually transmitted infections (formerly referred to as sexually transmitted diseases) they should be checked for and rely on their health care providers to order the proper tests and discuss the results with them.  Patient’s often will refer to being “clean” or “clear” when referring to their screening results.  When I ask them which infections they would like to be screened for, I usually hear something like “check me for everything.”

I think it’s important for patients to know which infections are most common, what the symptoms might be and know what to ask for when going to your doctor to be checked for sexually transmitted infections.  It’s also important to understand that some infections can be cured (with antibiotics), some infections can be controlled but never eradicated completely, and some infections can be present and not have any symptoms for years before becoming apparent.  Checking for “everything” might mean different things to different patients or medical providers, so my advice is to be very specific with what tests you request your medical provider order and keep track of the results so that when you think about “being clean” or “clear” of infection, you know exactly which infections you are clear of.

Types of infections:

1)  Chlamydia:  The most common sexually transmitted infection in the U.S.  This infection can cause pain and inflammation of the urethra (opening where urine comes out), the testicular area, the cervix and anus.  If untreated chlamydia can lead to infertility, chronic pelvic pain, prostatitis, and even severe infections of the fallopian tubes or tubal pregnancy.  Most men and women who are infected with chlamydia do not have symptoms.  Testing can be done with a urine sample from the patient or a swab.

2)  Herpes simplex virus:  It is estimated that about ¼ of the US population has herpes type 1 or 2 and many infected patients are unaware that they have the virus.  Skin ulcers are a result of the infection and increase the risk spreading or acquiring HIV.  Many patients with herpes are not screened because unless patient’s give a description of an ulcer in the genital area, a blood test for the antibodies to the viruses is usually not ordered.  If an ulcer is present, a swab may be collected by touching an open ulceration and sent for viral culture.  If you are concerned that you may have genital herpes, make sure you tell your medical provider and discuss testing with them because routine testing for herpes is usually not done unless there is some suspicion of infection.

3)  Gonorrhea:  The highest rates of infection are in sexually active 15-19yo women and 20-24yo men.  Rates are 20x higher in African-Americans than in whites.  Infection can lead to pain and inflammation of the urethra (opening where the urine comes out), sore throat and anal infection.  If untreated it can lead to serious complications in women including pelvic inflammatory disease and infertility.  Testing is frequently done from a urine sample or a swab.  Because of high rates of reinfection, patients diagnosed with gonorrhea should be advised to retest in 3 months.

4)  Trichomoniasis:  Infection with trichomonas produces symptoms similar to a urinary tract infection including pain and inflammation of the urethra (where the urine comes out), and/or vaginal discharge.  It can be present and men or women.  Most men who are infected do not have symptoms.  Testing is done by examination of a urine specimen.  Testing for trichomonas is not generally done on routine screening for STDs unless the patient asks for it or has symptoms.

5)  Syphilis:  Testing for syphilis is done with a standard blood test normally.  Symptoms of syphilis vary depending on the stage of infection.  Initially there is the appearance of a single sore mark, but there may be multiple sores.  The sore is usually firm, round and painless.  Because the sore is painless, it can easily go unnoticed.  It lasts 3-6 weeks and heals regardless of whether or not the person is treated.  If the infected person does not get treatment, the infection will progress to the second stage.  Skin rashes and/or sores in the mouth, vagina and anus (also called mucous membrane lesions) are typical of the second stage of symptoms.  The rash usually does not cause itching and may appear as rough, red or reddish brown spots both on the palms of the hands and/or the bottoms of the feet.  Sometimes rashes associated with secondary syphilis are so faint that they are not noticed.  Other symptoms of secondary syphilis include fever, swollen lymph glands, sore throat, patchy hair loss, headaches, weight loss, muscle aches, and fatigue.  The symptoms of secondary syphilis will go away with or without treatment.  Without appropriate treatment, the infection will progress to the latent and possibly late stages of disease.  The latent (hidden) stage can last for years.  About 15% of people who have not been treated for syphilis develop the late stage of the disease.  This stage can occur 10-30 years after the infection began and symptoms can include difficulty coordinating muscle movements, paralysis, numbness, gradual blindness, and dementia.  Damage to the internal organs, including the brain, nerves, eyes, heart, liver, bone and joints can occur and result in death.

6)  Hepatitis A, B and C:  Hepatitis that is transmitted by sexual contact is caused one of several different viruses (A, B or C).  All types of hepatitis virus infections can cause liver inflammation.  Hepatitis B and C can cause severe infection and lead to liver failure and death.  Hepatitis A is more commonly a cause of food-borne outbreaks.  Because there are vaccinations available for hepatitis A and B, we are seeing more patients recently developing hepatitis C because we currently do not have a protective immunization.  Hepatitis testing can be done through a simple blood test similar to HIV testing.  The initial test for hepatitis is usually done by trying to detect the antibody to the virus.  It can take your body several months after being infected with the hepatitis virus to develop the antibody and therefore there is a period of time called the “window period” when the test result may be negative even though the infection is present.  A repeat test is usually offered 3-6 months after the initial negative test for confirmation that the patient is negative after “high risk sexual contact.”

7)  Human Immunodeficiency virus (HIV):  It is important to recognize that patients who have been infected with other sexually transmitted infections may also be infected with HIV.  Recent recommendations from the Centers for Disease Control (CDC) recommend opt-out screening and annual screening for those at high risk for HIV infection.  The test for HIV is an antibody test.  Similar to hepatitis, it can take your body several months after being infected with HIV to develop the antibodies, and therefore there is a period of time called the “window period” when the test result may be negative even though infection is present.  Repeat testing 3-6 months after a previously negative result after “high risk sexual contact” is recommended.  HIV causes suppression of your natural immune system and can lead to a constellation of problems associated with immune suppression (infections, cancer) and AIDS related syndrome.

8)  Human papillomavirus (HPV):  This virus is the main cause of cervical cancer.  There are routine screening guidelines that have been established for pap smears which are the main way of detecting this virus and treating it before the development of cervical cancer.  All sexually active women should have a screening pap test by age 21.  Women between the ages of 9 and 26 years old are recommended to receive the HPV vaccine to prevent cervical dysplasia and cervical cancer.  Routine vaccination is recommended for female between 11 and 12 years, but the vaccination series may be started as early as 9 years and females aged 13-26 years can benefit as well.  The quadrivalent HPV vaccine can also be used in males and females aged 9-26 years of age to prevent genital warts and anogenital cancers.

Recommendations for screening for sexually transmitted infections in pregnant women, men who have sex with men, women who have sex with women and HIV infected patients vary depending on the risk group.

State health department notification:  Medical providers are required to notify the local and state public health departments in the case of chancroid, chlamydia, gonorrhea, acute hepatitis b, acute hepatitis c, HIV and syphilis.

Partner notification:  In the event that a patient has been diagnosed with a sexually transmitted infection, partners should be notified, examined and treated.  In some cases, the patient directly provides their sexual contact with medications and prescriptions to be filled (Partner Delivered Patient Medication (PDPM) although this is not legal in all states.  Patients and their partners should not have sexual relations until seven days after a single dose treatment or upon completion of a seven day regimen in cases of bacterial infections.  Discussion with sexual partners can be difficult but is very important for the partner’s safety and to prevent re-infection of the patient who tested positive initially.

2010 treatment/screening guidelines as outlined by the Centers for Disease Control in 2010:

  1. All patients being evaluated for STIs should be offered counseling and testing for HIV.
  2. Hepatitis B screening should be offered to men who have sex with men (MSM), injection drug users (IDU), persons attending an STI clinic or seeking STI treatment, and persons with history of multiple sex partners.  Patients who are not immune should be offered vaccination.
  3. Hepatitis A screening should be offered to MSM and injection drug users.  Those who are not immune should be offered vaccination.
  4. Asymptomatic women with risk factors for STIs should be screened for gonorrhea and chlamydia infection each year.
  5. Males and female between the ages of 9 and 26 years old should be offered the human papillomavirus vaccination (HPV vaccination).
  6. The following screening tests for active MSM are recommended on at least an annual basis:  HIV, gonorrhea, chlamydia, and syphilis.
  7. Syphilis screening is recommended for commercial sex workers, persons who exchange sex for drugs and persons in correctional facilities.
  8. Pregnant women should be screened for gonorrhea, chlamydia, HIV, hepatitis B, and syphilis infections.
  9. HIV-infected patients should be screened annually for gonorrhea, chlamydia, syphilis, hepatitis B and hepatitis C.  Vaccination against hepatitis A and B is recommended for nonimmune patients.  HIV-infected patients who actively use injection drugs or intranasal cocaine, engage in unprotected sex, are men who have sex with men, or are undergoing dialysis should have ongoing screening for hepatitis C.
  10. Local and state public health departments should be kept informed of notifiable infections, which include chancroid, chlamydia, gonorrhea, acute hepatitis A and acute hepatitis B, acute hepatitis C, HIV and syphilis.
  11. Partners should be notified, examined, and treated for the STI identified in the index patient.  Patients and their sex partners should abstain from sexual intercourse until therapy is completed.

References:  http://www.cdc.gov/std/treatment/2010/default/htm

Centers for Disease Control and Prevention.  Sexually Transmitted Disease Surveillance, 2008. US Department of Health and Human Services, Atlanta, GA 2009

US Preventative Services Task Force. Screening for gonorrhea.  Agency for Healthcare Research and Quality, Rockville, MD. Revised January 2006.

US Preventative Services Task Force. Screening for syphilis.  Agency for Healthcare Research and Quality, Rockville, MD. Revised January 2006.

US Preventative Services Task Force. Screening for herpes.  Agency for Healthcare Research and Quality, Rockville, MD. Revised January 2005.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com